Nursing Elites

1. A client with type 2 diabetes is admitted with hyperglycemic hyperosmolar syndrome (HHS). Which clinical finding is most concerning?

• A. Serum glucose of 500 mg/dl
• B. Blood pressure of 140/90 mmHg
• C. Serum osmolarity of 320 mOsm/kg
• D. Serum pH of 7.30

Correct answer: C

Rationale: A serum osmolarity of 320 mOsm/kg is the most concerning finding in a client with hyperglycemic hyperosmolar syndrome (HHS). This level of osmolarity indicates severe dehydration and hyperosmolarity, putting the client at risk of complications like organ failure. Immediate intervention is crucial to address the dehydration and restore fluid balance. The other options, while important in the overall assessment of a client with HHS, do not directly indicate the severity of dehydration and hyperosmolarity seen with a high serum osmolarity level.

2. An adult female client is admitted to the psychiatric unit because of a complex handwashing ritual she performs daily that takes two hours or longer to complete. She worries about staying clean and refuses to sit on any of the chairs in the day area. This client's handwashing is an example of which clinical behavior?

• A. Addiction
• B. Phobia
• C. Compulsion
• D. Obsession

Correct answer: C

Rationale: The client’s handwashing ritual is a compulsion, a repetitive behavior driven by the need to reduce anxiety associated with an obsession. In this case, the client's need to wash her hands excessively stems from an obsession with cleanliness, leading to the compulsive behavior of extensive handwashing. 'Addiction' (Choice A) involves a dependence on a substance or behavior, not related to this scenario. 'Phobia' (Choice B) is an intense fear of a specific object or situation, not applicable here. 'Obsession' (Choice D) refers to persistent and intrusive thoughts, while the handwashing behavior in this case is the compulsive action taken to alleviate the anxiety related to the obsession.

3. The nurse is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which assessment finding requires immediate intervention?

• A. Elevated blood pressure
• B. Increased fatigue
• C. Headache
• D. Elevated hemoglobin

Correct answer: A

Rationale: The correct answer is A: Elevated blood pressure. In a client with chronic kidney disease (CKD) receiving erythropoietin therapy, elevated blood pressure requires immediate intervention. This finding is concerning as it may indicate worsening hypertension, which can lead to further complications. Increased fatigue (choice B) is common in CKD but may not require immediate intervention unless severe. Headache (choice C) can be a symptom to monitor but does not pose an immediate threat like elevated blood pressure. Elevated hemoglobin (choice D) is actually a desired outcome of erythropoietin therapy and does not require immediate intervention.

4. In caring for a client with a PCA infusion of morphine sulfate through the right cephalic vein, the nurse assesses that the client is lethargic with a blood pressure of 90/60 mm Hg, a pulse rate of 118 beats per minute, and a respiratory rate of 8 breaths per minute. What assessment should the nurse perform next?

• A. Note the appearance and patency of the client's peripheral IV site.
• B. Palpate the volume of the client's right radial pulse.
• C. Auscultate the client's breath sounds bilaterally.
• D. Observe the amount and dose of morphine in the PCA pump syringe.

Correct answer: D

Rationale: In this scenario, the client is presenting with signs of potential opioid overdose, such as lethargy, hypotension, tachycardia, and bradypnea. The next assessment the nurse should perform is to observe the amount and dose of morphine in the PCA pump syringe. This evaluation is crucial in determining if the client is receiving an excessive amount of morphine, leading to the observed symptoms. Checking the PCA pump syringe will provide essential information to address the client's condition promptly and prevent further complications. Choices A, B, and C are not the priority in this situation as they do not directly address the potential cause of the client's symptoms related to morphine administration.

5. The nurse is preparing a 50 ml dose of 50% dextrose IV for a client with insulin shock. What is the most immediate intervention by the nurse?

• A. Dilute the dextrose in one liter of 0.9% Normal Saline solution.
• B. Mix the dextrose in a 50 ml piggyback for a total volume of 100 ml.
• C. Push the undiluted dextrose slowly through the current IV infusion.
• D. Ask the pharmacist to add the dextrose to a TPN solution.

Correct answer: C

Rationale: The correct immediate intervention by the nurse in this situation is to push the undiluted 50% dextrose slowly through the current IV infusion. This is because in cases of insulin shock, where the client has dangerously low blood sugar levels, administering 50% dextrose directly into the bloodstream helps rapidly increase blood glucose levels. Choice A is incorrect because diluting the dextrose in one liter of normal saline would delay the administration of glucose, which is needed urgently. Choice B is incorrect as mixing the dextrose in a piggyback solution would also delay the administration of the concentrated dextrose. Choice D is incorrect because adding dextrose to a TPN solution is not the immediate intervention needed to address the low blood sugar levels in a client experiencing insulin shock.

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